United States District Court, D. Massachusetts
MEMORANDUM OF DECISION AND ORDER ON PLAINTIFF'S MOTION TO TAKE LIMITED FOCUSED DISCOVERY
JUDITH GAIL DEIN, Magistrate Judge.
The plaintiff, Bruce Tracia, was a business account executive at Comcast Corporation ("Comcast"). He stopped working on May 10, 2011 as a result of ankle related pain, for which he ultimately underwent surgery. Tracia subsequently was diagnosed with complex regional pain syndrome as well as various other medical conditions. He has brought this action under the Employee Retirement Income Security Act of 1974 ("ERISA") seeking to recover long term disability ("LTD") benefits under the terms of an LTD benefits policy issued by the defendant Liberty Life Assurance Co. ("Liberty"). After initially approving Tracia for LTD benefits, and after Tracia qualified for social security benefits, Liberty determined that Tracia no longer qualified for LTD benefits, and terminated those benefits by letter dated November 9, 2012. Plaintiff challenges that denial as being arbitrary and capricious, and he argues that the decision was influenced by a conflict of interest since Liberty is both the ERISA plan's administrator and the payer of benefits.
The matter is before the court on the Plaintiff's Motion to Take Limited Discovery (Docket No. 22). By his motion, Tracia is seeking discovery concerning the number and outcome of medical reviews undertaken by James Lee Lewis, M.D., Harold E. Gottlieb, M.D. and Ephraim K. Brenman, D.O., all of whom had participated in the review of his file which resulted in the denial of his request for LTD benefits. He is also seeking information and documents about the relationship between Liberty and MCMC LLC, the entity which procured the services of the doctors for Liberty.
For the reasons detailed herein, the Motion is DENIED.
A detailed review of the plaintiff's medical history is not necessary or appropriate at this stage, since the sole issue before this court is whether the administrative record ("AR") should be supplemented with additional discovery. The merits of Tracia's entitlement to LTD benefits are not presently before this court.
Liberty issued a Group Disability Income Policy to Comcast that provided for LTD benefits. (AR 1). Under the relevant definition of "disability, " a plan participant qualifies for LTD benefits for 12 months if he is unable to perform the material and substantial duties of his "own occupation." (AR 9). Thereafter, a plan participant qualifies for LTD benefits if he is unable to perform the material and substantial duties of "any occupation." (Id.). Liberty, as the plan administrator, was granted "the authority, in its sole discretion, to construe the terms of this policy and to determine benefit eligibility[.]" (AR 42). The plan provides further that Liberty's "decisions regarding construction of the terms of this policy and benefit eligibility shall be conclusive and binding." (Id.).
As noted above, Tracia stopped working on May 10, 2011. He underwent surgery for tarsal tunnel syndrome on June 3, 2011. After receiving the full-term of short-term disability benefits under the plan, by letter dated November 29, 2011, Liberty notified the plaintiff that he qualified for long-term disability benefits, effective November 15, 2011. (AR 2362-63). In connection with its decision, Liberty obtained a peer review analysis by Steven M. Lobel, M.D. and information from plaintiff's physician, Dr. Rathmall. Dr. Lobel had been referred to Liberty by MCMC, LLC. (AR 2375-76).
After approving Tracia for long-term benefits, Liberty continued to review plaintiff's claim. Based on his policy, Liberty also required him to apply for benefits with the Social Security Administration ("SSA"). (AR 2363). Tracia did apply for such benefits, which were awarded. In connection with its own continued review, Liberty sent plaintiff's claim for an "independent review" by Gregg G. Marella M.D., who was Board Certified in Internal Medicine (AR 1716-20), and Ephraim K. Brenman, D.O., who was Board Certified in Physical Medicine and Rehabilitation. (AR 1734-43). These physicians were referred by a third party vendor, MES Solutions. (Id.). Dr. Brenman opined that while plaintiff had physical restrictions in, inter alia, walking, climbing, and standing, he had a sustained full-time sedentary capacity. (AR 1742). In connection with his report, Dr. Brenman certified, among other things, that he "does not accept compensation for any review activities that is dependent in any way on the specific outcome of the case." (Id.). Liberty also obtained a review by a Vocational Specialist who opined that the plaintiff could engage in various occupations. (AR 1725-28). After obtaining this information, Liberty discontinued plaintiff's LTD benefits effective November 15, 2012. (AR 1716).
Plaintiff appealed the decision to discontinue benefits. As part of the appeal, Liberty referred the claim file for independent medical peer review to Harold E. Gottlieb, M.D., who was Board Certified in Internal Medicine (AR 95-113), and Jamie L. Lewis, M.D., who was Board Certified in Physical Medicine & Rehabilitation/Pain Medicine and Physical Medicine & Rehabilitation. (AR 146-65). These independent reviewing physicians were referred by MCMC. (AR 231-36). Dr. Lewis opined, based on his record review, that after November 14, 2012, plaintiff would have sustained capacity for full time work, with some restrictions regarding lifting, walking and standing, but no restrictions regarding use of his upper extremities, or sitting. (AR 163-64). Dr. Lewis certified that compensation for his review was "not dependent, in any way, on the outcome of this case." (AR 164-65). Dr. Gottlieb conducted a record review, and also spoke with plaintiff's attending physician, Dr. Chin. (AR 95-112). Dr. Gottlieb opined that the plaintiff had the "sustained capacity for full time work without restrictions or limitations." (AR 109). He also certified that his compensation was "not dependent, in any way, on the outcome of this case." (AR 109-110). Another vocational analysis confirmed that the plaintiff was still able to perform the previously identified occupations. (AR 50). By letter dated August 12, 2013, Liberty upheld its original decision to discontinue benefits beyond November 14, 2012. (AR 88-94). This appeal followed.
Additional facts will be provided below where appropriate.
Where, as here, the ERISA "plan documents delegate discretionary authority to the plan administrator (whether or not structurally conflicted), courts should review benefitdenial decisions for abuse of discretion, considering any conflict as one of a myriad of relevant factors." Denmark v. Liberty Life Assur. Co. of Boston ("Denmark III"), 566 F.3d 1, 9 (1st Cir. 2009). Under this standard, "benefit-denial cases typically are adjudicated on the record compiled before the plan administrator." Id. at 10. "The longstanding rule in the First Circuit holds that some very good reason is needed to overcome the strong presumption that the record on review is limited to the record before the administrator.'" McGahey v. Harvard Univ. Flexible Benefits Plan, Civil Action No. 08-10435-RGS, 2009 WL 799464, at *2 (D. Mass. Mar. 25, 2009) (quoting Liston v. Unum Corp. Officer Severance Plan, 330 F.3d 19, 23 (1st Cir. 2003)). "In some cases, a good reason has been found to exist when a party makes a colorable claim of bias." Denmark III, 566 F.3d at 10. In that situation, "targeted discovery" on the issue "whether a structural conflict has morphed into an actual conflict" may be permissible to "shed new light on the ...